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'?AGE OF <br /> MONITORING WELL INSTALLATION REPORT <br /> Date:_._ _ f CONSTRUCTION <br /> Premise Addr ss: 3 Well No. <br /> Inspector• Total Depth ' <br /> Screen Lengthy r <br /> Filter Pack <br /> Bentonite <br /> Permit No. Grout <br /> Consultant LACompletion-Stovepipeistie box <br /> Geologist <br /> Auger O.D. d <br /> Auger I.D. <br /> SAMPLING <br /> Holding Temperature stk*-up <br /> Method <br /> Screening Method <br /> ABOVEGROUND CHRISTY-BOX <br /> Tracking Sheet {y/n) COMPLETION COMPLETION <br /> G=nd Surface <br /> SPOILS <br /> �y , r grout <br /> Storage Method ry-[ems_ 6n <br /> Contamination Noted - ff <br /> yes/no �( n• <br /> Storage Location _ �.s �• n• <br /> a <br /> SPECIAL PERMIT INFO. • <br /> 0 <br /> 7 5 l cloned <br /> Distance to sewer line &*don — <br /> Domestic well on site - ye no = gm�Wpack <br /> If yes, location & distance - <br /> 35 _ -3-S n, <br /> GROUTING <br /> MATERIALS USED: <br /> Depth to water [ Casing �tsype T <br /> Mix Ratios / ba /0 _ Blank ft. Screen ft. <br /> Installation Met,(/Cd' Slot size , D.-1- <br /> Quantity <br /> .-1-Quantity Installed U Bags cement <br /> bentonite =� <br /> Bags sand/gravel <br /> Filter Pack type/size <br /> Total Billed Time Per Site <br /> Date Permit Finalized <br />